Reimbursement Guide
®
TABLE OF CONTENTS Coding Basics and Mobi-C® Technology Overview.....................................................3 Diagnosis Coding (ICD-9).....................................................................................................4 Physician Reimbursement (CPT).......................................................................................5 Hospital Reimbursement - Inpatient (DRG)..................................................................8 Hospital Reimbursement - Outpatient (APC)...............................................................8
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Disclaimer: The information contained in this document has been prepared by reimbursement and coding professionals to assist you in understanding the reimbursement process. It is intended to assist providers in accurately obtaining reimbursement for health care services. It is not intended to increase or maximize reimbursement by any payor. We strongly suggest that you consult your payor organization with regard to local reimbursement policies. The information contained in this document is provided for informational purposes only and represents no statement, promise, or guarantee by LDR concerning levels of reimbursement, payment, charge, or guarantee that these codes will be appropriate in every case, or that third-party reimbursement will be made.
Coding Basics & Technology Overview The Mobi-C® Cervical Disc Prosthesis is indicated in skeletally mature patients for reconstruction of the disc from C3-C7 following discectomy at one level or two contiguous levels for intractable radiculopathy (arm pain and/or a neurological deficit) with or without neck pain, or myelopathy due to abnormality localized to the level of the disc space and at least one of the following conditions confirmed by radiographic imaging (CT, MRI, X-rays): herniated nucleus pulposus, spondylosis (defined by the presence of osteophytes), and/or visible loss of disc height compared to adjacent levels. The Mobi-C® Cervical Disc Prosthesis is implanted using an anterior approach. Patients should have failed at least 6 weeks of conservative treatment or demonstrated progressive signs or symptoms despite nonoperative treatment prior to implantation of the Mobi-C® Cervical Disc Prosthesis. The Mobi-C Cervical Disc is designed to provide pain relief following disc excision, while also allowing for normal biomechanical function and potentially preventing the subsequent degeneration of adjacent discs. Mobi-C was also designed to minimize stress between implant and bone by way of the mobile core, thus eliminating the need for more traumatic fixation mechanisms such as keels or screws that cut deeply into the bone. The device consists of the following components: •
An inferior and superior plate which allow for fully congruent contact surfaces between the plates and the mobile insert.
•
An ultra-high molecular weight polyethylene mobile insert, featuring a superior convex spherical dome and inferior flat surface, between the spinal plates, thereby allowing for various degrees of mobility.
•
Movement of the superior plate is designed to induce the mobile insert to re-position on the inferior plate, thereby allowing natural superior and inferior vertebral alignment. Rotation Latera
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± 10° Lateral Bend
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± 10° Flexion/Extension
Mobi-C received FDA approval on August 7 and August 23, 2013, and is indicated for use at one-level or two contiguous levels. Current coding for cervical disc arthroplasty and the implantation of Mobi-C for both one and two-level indications follows. Physician, hospital outpatient, and hospital inpatient coding is provided in this document, along with key considerations for addressing the status of the codes provided. The 2013 Medicare national average reimbursement rates have also been provided for applicable codes.
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Diagnosis Coding (ICD-9) Diagnosis codes are assigned by the physician to accurately report the patient’s condition as it relates to the procedure. Below is a listing of diagnosis codes and definitions that may apply to patients requiring cervical disc arthroplasty using Mobi-C at one-level or two contiguous levels. This is only a listing of possible codes that represent the typical diagnoses associated with the procedure and is not intended to be a complete list. No actual patient condition is represented by the examples provided.
ICD-9-CM Diagnosis Codes ICD-9-CM Code1 721.0 721.1 722.0 722.4 722.71 722.81
Diagnosis Description Cervical spondylosis without myelopathy Cervical spondylosis with myelopathy Displacement of cervical intervertebral disc without myelopathy Degeneration of cervical intervertebral disc Intervertebral cervical disc disorder with myelopathy, cervical region Postlaminectomy syndrome, cervical region
Indication Checklist Patient must demonstrate all of the following: FF Is skeletally mature FF Needs disc reconstruction between C3 and C7 at one-level or two contiguous levels FF Has failed at least 6 weeks of conservative treatment or shows signs of progressively worsening symptoms, despite treatments outside of surgery FF Has at least one of the following: FF Intractable radiculopathy (arm pain and/or a neurological deficit) which can have associated neck pain as well FF Myelopathy (due to abnormality localized to the level of the disc space) FF Has at least one of the following for each level upon which is being operated, confirmed by radiographic imaging FF Herniated nucleus pulposus (i.e. herniated disc) FF Spondylosis (i.e. the presence of osteophytes) FF Loss of disc height (compared to neighboring levels) 1
2013 Expert ICD-9-CM for Hospitals-Volumes 1,2 &3, 2012 www.CMS.gov
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Physician Reimbursement: Current Procedural Terminology Physician Current Prodecural Terminology (CPT2) coding for single level cervical disc arthroplasty (22856) is available and well-established. CPT coding for a second level of cervical disc arthroplasty is currently reported with a temporary Category III code (0092T). Category III codes represent emerging technologies and are not assigned relative value units (RVUs) that can be translated into payments. Because Category III codes (such as 0092T) do not have established RVUs by Medicare, providers submitting Category III codes for reimbursement must also submit a “special report” explaining the procedure details and an accompanying “crosswalk code,” which is used to establish a reimbursement value. Established Physician Coding Pathways for Mobi-C have been provided below, along with Medicare national average payment rates.3 CPT codes used to denote one-level and two-level procedures have been provided, as have revision and removal codes. Physician Coding Pathways CPT-4 Code4
22856
0092T
22861
0098T
Medicare National 2013 RVUs Average Payment 20135,6
CPT Description Mobi-C Implantation First Level Total disc arthroplasty (artificial disc), anterior approach, including discectomy with endplate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), single interspace, cervical Mobi-C Implantation Second Level Total disc arthroplasty (artificial disc), anterior approach, including discectomy with endplate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), each additional interspace, cervical (List separately in addition to code for primary procedure) Mobi-C Implantation + Cervical Disc Replacement Revision First Level Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace, cervical
Category III Code No RVUs Established
Mobi-C Implantation + Cervical Disc Replacement Revision Second Level Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure)
Category III Code No RVUs Established
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49.53
66.06
$1,685
Case by Case Reimbursement
$2,248
Case by Case Reimbursement
Physician Coding Pathways (continued) CPT-4 Code4
22864
0095T
CPT Description Cervical Disc Removal First Level Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace, cervical
Medicare National 2013 RVUs Average Payment 20135,6
59.00
Cervical Disc Removal Second Level Category III Removal of total disc arthroplasty (artificial disc), anterior Code approach, each additional interspace, cervical (List separately in No RVUs addition to code for primary procedure) Established
$2,007
Case by Case Reimbursement
Current Procedural Terminology. The Medicare national average payment amounts provided in this guide do not reflect the 2% payment reduction required by the sequestration provisions of the Budget Control Act of 2011. 4 CPT 2013 Professional Edition, 2012 American Medical Association (AMA); CPT is a trademark of the AMA. 5 2013 Medicare Physician Fee Schedule RVU multiplied by conversion factor 34.0376, effective January, 2013. 6 The 2013 Medicare national average rates provided have been calculated using the RVUs and conversion factor available at the time this document was created. These rates and RVUs are subject to change by act of Congress and the actual rates adopted for 2013 physician reimbursement, by Final Rule, may differ. 2 3
Mobi-C Physician Coding Scenario A coding scenario has been prepared to illustrate coding for two-level implantation of Mobi-C®. As indicated below, the primary procedure (or first level) is valued with a straightforward method utilizing Medicareestablished RVUs. Because Category III codes (such as 0092T) do not have established RVUs, the provider must also submit a “special report” explaining the procedure details and an accompanying “crosswalk code” used to establish a reimbursement value. “Special Report” – Written narrative detailing the scope and work involved in the procedure represented by the Category III code (in this case 0092T, which reports the second level implantation of Mobi-C). “Crosswalk Code” – An established permanent CPT code determined by the physician to be similarly valued to the work, risk, and time involved in the reported Category III procedure code. This code is not directly reimbursed but allows the payor to gauge the reimbursement value and provide appropriate reimbursement based on a review of the procedure and reported value as compared to the “crosswalk code.” In the following example a “crosswalk code” and CPT 22552, has been utilized. CPT 22552 currently represents a second level anterior cervical fusion procedure performed in addition to the primary anterior interbody arthrodesis. This code is not reportable for a second level anterior cervical disc arthroplasty directly, but represents a procedure with similar work, risk and time for reimbursement comparison. Providers may identify alternate “crosswalk codes” for their claim submissions. Again, it is necessary for the physician to provide an accompanying “special report” to detail and justify the second level procedure, as well as the choice of the comparison code. 6
Mobi-C Physician Coding Scenario continued Physician Coding Scenario The surgeon performs a two-level Mobi-C procedure involving an anterior total disc cervical arthroplasty at two levels, including discectomy with endplate preparation. CPT Code
22856
0092T
Description Mobi-C Implantation First Level Total disc arthroplasty (artificial disc), anterior approach, including discectomy with endplate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), single interspace, cervical Mobi-C Implantation Second Level Total disc arthroplasty (artificial disc), anterior approach, including discectomy with endplate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), each additional interspace, cervical (List separately in addition to code for primary procedure) TOTAL PHYSICIAN REIMBURSEMENT
2013 RVU’s
Medicare National Average Payment 20135,6
49.53
$1,685
“Crosswalk Code” 22552 RVU = 11.63
$395
$2,080
Note: The “crosswalk code” provided above is used as a proxy for valuation of the reported procedure. It is NOT intended to be reported itself for reimbursement but is only used as a guide for third party reimbursement consideration. Actual payments are determined by the payor at the time of adjudication of the claim. 2013 Medicare Physician Fee Schedule RVU multiplied by conversion factor 34.0376, effective January, 2013. The 2013 Medicare national average rates provided have been calculated using the RVUs and conversion factor available at the time this document was created. These rates and RVUs are subject to change by act of Congress and the actual rates adopted for 2013 physician reimbursement, by Final Rule, may differ. 5 6
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Hospital Inpatient Reimbursement (DRG) Hospital inpatient coding pathways are established for anterior cervical total disc arthroplasty procedures such as Mobi-C. One and two-level Mobi-C procedures are assigned to the same Medical Severity Diagnosis Related Group (MS-DRG) for the hospital stay. The following hospital inpatient ICD-9-CM codes are established for the Mobi-C procedure and its revision or replacement. These codes contribute to the established MS-DRG for the entire inpatient stay.
Hospital Procedure Coding Pathways ICD-9-CM Code7
ICD-9-CM Description
84.62 84.66
Insertion of total spinal disc prosthesis, cervical Revision or replacement of artificial spinal disc prosthesis, cervical
The implantation of Mobi-C in the inpatient setting is assigned to MS-DRG 490 (elevated from MS-DRG 491, of lower value) due to the use of the artificial disc prosthesis implanted during the procedure.
Hospital Inpatient Likely MS-DRG Assignment MS-DRG8
MS-DRG Description
Medicare National Average Payment 2013
490
Back and Neck Procedures Except Spinal Fusion with CC/MCC or Disc Device/Neurostimulator
$10,483
Hospital Outpatient Reimbursement (APC) CPT code 22856, used to denote single level cervical disc arthroplasty, has recently been added to the Medicare Outpatient allowable list for 2013 and is therefore reimbursable by Medicare in this alternate setting of care. Previously, this procedure was only allowable by Medicare in the inpatient setting. The second level code, 0092T, has not been added to this outpatient list and is still considered an inpatient-only procedure for Medicare patients. Private payor guidelines may differ from Medicare, so that two-level cervical disc arthroplasty procedures may be permissible in the outpatient setting of care. The 2013 Medicare coding pathway for the single level Mobi-C procedure in the hospital outpatient setting of care follows. CPT code 22856 is assigned to Ambulatory Payment Classification (APC) 0208, as indicated below:
Hospital Outpatient Coding Pathways CPT
CPT Description
APC
Medicare Hospital Outpatient Rate 20139
22856
Mobi-C Implantation First Level Total disc arthroplasty (artificial disc), anterior approach, including discectomy with endplate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), single interspace, cervical
0208
$3,759
2013 Expert ICD-9-CM for Hospitals-Volumes 1, 2 & 3, 2012, Optum. 2013 MS-DRG relative weight multiplied by 2013 rate per IPPS Final Rule. Payment rates will vary by facility. Calculation includes labor related, non-labor related and capital payment rates. 9 2013 Medicare Outpatient Prospective Payment System Final Rule for 2012. www.cms.gov 2013. 7
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Indications for Use The Mobi-C® Cervical Disc Prosthesis is indicated in skeletally mature patients for reconstruction of the disc from C3-C7 following discectomy at one level or two contiguous levels for intractable radiculopathy (arm pain and/or a neurological deficit) with or without neck pain, or myelopathy due to abnormality localized to the level of the disc space and at least one of the following conditions confirmed by radiographic imaging (CT, MRI, X-rays): herniated nucleus pulposus, spondylosis (defined by the presence of osteophytes), and/or visible loss of disc height compared to adjacent levels. The Mobi-C® Cervical Disc Prosthesis is implanted using an anterior approach. Patients should have failed at least 6 weeks of conservative treatment or demonstrated progressive signs or symptoms despite nonoperative treatment prior to implantation of the Mobi-C® Cervical Disc Prosthesis.
Note: Please refer to the Mobi-C Summary of Safety and Effectiveness Data (PMA P110002, PMA P110009) at www.fda.gov for complete study results.
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Notes
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REF: MB B 9 REV A 08.2013 ®
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